What is a cholesteatoma?

A cholesteatoma is a skin growth that occurs in an abnormal location,
the middle ear behind the eardrum. It is usually due to repeated infection, which causes
an ingrowth of the skin of the eardrum. Cholesteatomas often take the form of a cyst or
pouch which sheds layers of old skin that builds up inside the ear. Over time, the
cholesteatoma can increase in size and destroy the surrounding delicate bones of the
middle ear. Hearing loss, dizziness, and facial muscle paralysis are rare but can result
from continued cholesteatoma growth.

How does it occur?

A cholesteatoma usually occurs because of poor eustachian tube function
as well as infection in the middle ear. The eustachian tube conveys air from the back of
the nose into the middle ear to equalize ear pressure ("clear the ears"). When
the eustachian tubes work poorly perhaps due to allergy, a cold or sinusitis, the air in
the middle ear is absorbed by the body, and a partial vacuum results in the ear. The
vacuum pressure sucks in a pouch or sac by stretching the eardrum, especially areas
weakened by previous infections. This sac often becomes a cholesteatoma. A rare congenital
form of cholesteatoma (one present at birth) can occur in the middle ear and elsewhere,
such as in the nearby skull bones. However, the type of cholesteatoma associated with ear
infections is most common.

What are the symptoms?

Initially, the ear may drain, sometimes with a foul odor. As the
cholesteatoma pouch or sac enlarges, it can cause a full feeling or pressure in the
ear, along with hearing loss. (An ache behind or in the ear, especially at
night, may cause significant discomfort.) Dizziness, or muscle weakness on one side of the
face (the side of the infected ear) can also occur. Any, or all, of these symptoms are
good reasons to seek medical evaluation.

Is it dangerous?

Ear cholesteatomas can be dangerous and should never be ignored. Bone
erosion can cause the infection to spread into the surrounding areas, including the inner
ear and brain. If untreated, deafness, brain abscess, meningitis, and rarely death can
occur.

What treatment can be provided?

An examination by an otolaryngologist-head and neck surgeon can confirm
the presence of a cholesteatoma. Initial treatment may consist of a careful cleaning of
the ear, antibiotics, and ear drops. Therapy aims to stop drainage in the ear by
controlling the infection. The extent or growth characteristics of a cholesteatoma must
also be evaluated.

Large or complicated cholesteatomas usually require surgical treatment
to protect the patient from serious complications. Hearing and balance tests, x-rays of
the mastoid (the skull bone next to the ear), and CAT scans (3-D x-rays) of the mastoid
may be necessary. These tests are performed to determine the hearing level remaining in
the ear and the extent of destruction the cholesteatoma has caused.

Surgery is performed under general anesthesia in most cases. The
primary purpose of the surgery is to remove the cholesteatoma and infection and achieve an
infection-free, dry ear. Hearing preservation or restoration is the second goal of
surgery. In cases of severe ear destruction, reconstruction may not be possible. Facial
nerve repair or procedures to control dizziness are rarely required. Reconstruction of the
middle ear is not always possible in one operation; and therefore, a second operation may
be performed six to twelve months later. The second operation will attempt to restore
hearing and, at the same time, inspect the middle ear space and mastoid for residual
cholesteatoma.

Admission to the hospital is usually done the morning of surgery, and
if the surgery is per-formed early in the morning, discharge maybe the same day. For some
patients, an overnight stay is necessary. In rare cases of serious infection, prolonged
hospitalization for antibiotic treatment may be necessary. Time off from work is typically
one to two weeks.

Follow-up office visits after surgical treatment are necessary and
important, because cholesteatoma sometimes recurs. In cases where an open mastoidectomy
cavity has been created, office visits every few months are needed in order to clean out
the mastoid cavity and prevent new infections. In some patients, there must be lifelong
periodic ear examinations.

SUMMARY

Cholesteatoma is a serious but treatable ear condition which can only
be diagnosed by medical examination. Persisting earache, ear drainage, ear pressure,
hearing loss, dizziness, or facial muscle weakness signals the need for evaluation by an
otolaryngologist-head and neck surgeon.

WHAT IS OTOLARYNGOLOGY-HEAD AND NECK SURGERY?

Otolaryngology-head and neck surgery is a specialty concerned with the
medical and surgical treatment of the ears, nose, throat and related structures of the
head and neck. The specialty encompasses cosmetic facial reconstruction, surgery of benign
and malignant tumors of the head and neck, management of patients with loss of hearing and
balance, endoscopic examination of air and food passages, and treatment of allergic,
sinus, laryngeal, thyroid and esophageal disorders.

To qualify for the American Board Otolaryngology certification
examination, a physician must complete five or more years of post-M.D. (or D.O.) specialty
training.